Treatment of Osteoarthritis

  • David Hunter


In the absence of a cure for osteoarthritis, current therapeutic modalities are primarily aimed at reducing pain and improving joint function by targeting symptom relief, without facilitating any improvement in the joint structure itself [1]. The management of osteoarthritis should be individualised so that it conforms to the specific findings of the clinical examination (Figure 6.1) [2]. This is especially the case for patients with obesity, malalignment and/or muscle weakness. Comprehensive management always includes a combination of treatment options that are directed towards the common goal of improving the patient’s pain and tolerance for functional activity. Treatment plans should never be defined rigidly based on the X-ray appearance of the joint, but instead remain flexible so that they can be altered in line with the functional and symptomatic responses obtained [2]. Guidelines recommend that the hierarchy of management should consist of nonpharmacological modalities first, then drugs and then surgery [3–7].


Knee Osteoarthritis High Tibial Osteotomy Glucosamine Sulfate Topical NSAID Unicompartmental Knee Replacement 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Hunter DJ, Lo GH. The management of osteoarthritis: an overview and call to appropriate conservative treatment. Rheum Dis Clin North Am. 2008;34:689-712.Google Scholar
  2. 2.
    Hunter DJ, Felson DT. Osteoarthritis. BMJ. 2006;332:639-642.Google Scholar
  3. 3.
    Jordan KM, Arden NK, Doherty M, et al; Standing Committee for International Clinical Studies Including Therapeutic Trials. EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003;62:1145-1155.Google Scholar
  4. 4.
    Zhang W, Doherty M, Arden N, et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics. EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2005;64:669-681.Google Scholar
  5. 5.
    Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-162.Google Scholar
  6. 6.
    Richmond J, Hunter D, Irrgang JJ, Jet al; American Academy of Orthopaedic Surgeons Workgroup. Treatment of osteoarthritis of the knee (nonarthroplasty): full guideline. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008.Google Scholar
  7. 7.
    Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64:465-474.Google Scholar
  8. 8.
    Superio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. Arthritis Care Res. 1996;9:292-301.Google Scholar
  9. 9.
    Arthritis Foundation website. Disease Center. Available at: Accessed 8 October 2012.
  10. 10.
    Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I). Health Promot Pract. 2005;6:37-43.Google Scholar
  11. 11.
    Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med. 2000;133:635-646.Google Scholar
  12. 12.
    Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum. 2004;50:1501-1510.Google Scholar
  13. 13.
    Hutchings A, Calloway M, Choy E, et al. The Longitudinal Examination of Arthritis Pain (LEAP) study: relationships between weekly fluctuations in patient-rated joint pain and other health outcomes. J Rheumatol. 2007;34:2291-2300.Google Scholar
  14. 14.
    DeHaan MN, Guzman J, Bayley MT, Bell MJ. Knee osteoarthritis clinical practice guidelines – how are we doing? J Rheumatol. 2007;34:2099-2105.Google Scholar
  15. 15.
    Jordan KM, Sawyer S, Coakley P, Smith HE, Cooper C, Arden NK. The use of conventional and complementary treatments for knee osteoarthritis in the community. Rheumatology (Oxford). 2004;43:381-384.Google Scholar
  16. 16.
    American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum. 2000;43:1905-1915.Google Scholar
  17. 17.
    Hunter DJ. In the clinic. Osteoarthritis. Ann Intern Med 2007;147:ITC8-1-ITC8-16.Google Scholar
  18. 18.
    Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet. 2011;378:815-825.Google Scholar
  19. 19.
    Glazier RH, Dalby DM, Badley EM, et al. Management of common musculoskeletal problems: a survey of Ontario primary care physicians. CMAJ. 1998;158:1037-1040.Google Scholar
  20. 20.
    Messier S, Nicklas B, Legault C, et al. The Intensive Diet and Exercise for Arthritis (IDEA) trial: 18-month clinical outcomes. Paper presented at: 2011 American College of Rheumatology/Association of Rheumatology Health Professionals Annual Meeting; November 5–9, 2011; Chicago, IL.Google Scholar
  21. 21.
    Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010;18:476-499.Google Scholar
  22. 22.
    Baker KR, Nelson ME, Felson DT, Layne JE, Sarno R, Roubenoff R. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28:1655-1665.Google Scholar
  23. 23.
    Ettinger WH Jr, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA. 1997;277:25-31.Google Scholar
  24. 24.
    O’Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis. 1999;58:15-19.Google Scholar
  25. 25.
    Røgind H, Bibow-Nielsen B, Jensen B, Møller HC, Frimodt-Møller H, Bliddal H. The effects of a physical training program on patients with osteoarthritis of the knees. Arch Phys Med Rehabil. 1998;79:1421-1427.Google Scholar
  26. 26.
    Fisher NM, Gresham GE, Abrams M, Hicks J, Horrigan D, Pendergast DR. Quantitative effects of physical therapy on muscular and functional performance in subjects with osteoarthritis of the knees. Arch Phys Med Rehabil. 1993;74:840-847.Google Scholar
  27. 27.
    Baker K, McAlindon T. Exercise for knee osteoarthritis. Curr Opin Rheumatol. 2000;12:456-463.Google Scholar
  28. 28.
    Fisher NM, White SC, Yack HJ, Smolinski RJ, Pendergast DR. Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation. Disabil Rehabil. 1997;19:47-55.Google Scholar
  29. 29.
    Bennell KL, Hunt MA, Wrigley TV, Lim BW, Hinman RS. Role of muscle in the genesis and management of knee osteoarthritis. Rheum Dis Clin North Am. 2008;34:731-754.Google Scholar
  30. 30.
    Bennell KL, Hunter DJ, Hinman RS. Management of osteoarthritis of the knee. BMJ. 2012;345:e4934.Google Scholar
  31. 31.
    Gross KD, Hillstrom HJ. Noninvasive devices targeting the mechanics of osteoarthritis. Rheum Dis Clin North Am. 2008;34:755-776.Google Scholar
  32. 32.
    Gross KD. Device use: walking aids, braces, and orthoses for symptomatic knee osteoarthritis. Clin Geriatr Med. 2010;26:479-502.Google Scholar
  33. 33.
    Harvey WF, Hunter DJ. The role of analgesics and intra-articular injections in disease management. Rheum Dis Clin North Am. 2008;34:777-788.Google Scholar
  34. 34.
    Lo GH, LaValley M, McAlindon T, Felson DT. Intra-articular hyaluronic acid in treatment of knee osteoarthritis: a meta-analysis. JAMA. 2003;290:3115-3121.Google Scholar
  35. 35.
    Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354:795-808.Google Scholar
  36. 36.
    Ortiz E. Market withdrawal of Vioxx: is it time to rethink the use of COX-2 inhibitors? J Manag Care Pharm. 2004;10:551-554.Google Scholar
  37. 37.
    Bookman AA, Williams KS, Shainhouse JZ. Effect of a topical diclofenac solution for relieving symptoms of primary osteoarthritis of the knee: a randomized controlled trial. CMAJ. 2004;171:333-338.Google Scholar
  38. 38.
    Lin J, Zhang W, Jones A, Doherty M. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomised controlled trials. BMJ. 2004;329:324.Google Scholar
  39. 39.
    Altman R, Barkin RL. Topical therapy for osteoarthritis: clinical and pharmacologic perspectives. Postgrad Med. 2009;121:139-147.Google Scholar
  40. 40.
    Conaghan P, Birrell F, Burke M, et al; Guideline Development Group for The National Collaborating Centre for Chronic Conditions. Osteoarthritis: National Clinical Guideline for Care and Management in Adults. London, UK: Royal College of Physicians; 2008.Google Scholar
  41. 41.
    Harvey WF, Hunter DJ. Pharmacologic intervention for osteoarthritis in older adults. Clin Geriatr Med. 2010;26:503-515.Google Scholar
  42. 42.
    Case JP, Baliunas AJ, Block JA. Lack of efficacy of acetaminophen in treating symptomatic knee osteoarthritis: a randomized, double-blind, placebo-controlled comparison trial with diclofenac sodium. Arch Intern Med. 2003;163:169-178.Google Scholar
  43. 43.
    Golden HE, Moskowitz RW, Minic M. Analgesic efficacy and safety of nonprescription doses of naproxen sodium compared with acetaminophen in the treatment of osteoarthritis of the knee. Am J Ther. 2004;11:85-94.Google Scholar
  44. 44.
    Miceli-Richard C, Le Bars M, Schmidely N, Dougados M. Paracetamol in osteoarthritis of the knee. Ann Rheum Dis. 2004;63:923-930.Google Scholar
  45. 45.
    Pincus T, Koch G, Lei H, et al. Patient Preference for Placebo, Acetaminophen (paracetamol) or Celecoxib Efficacy Studies (PACES): two randomised, double blind, placebo controlled, crossover clinical trials in patients with knee or hip osteoarthritis. Ann Rheum Dis. 2004;63:931-939.Google Scholar
  46. 46.
    Pincus T, Swearingen C, Cummins P, Callahan LF. Preference for nonsteroidal antiinflammatory drugs versus acetaminophen and concomitant use of both types of drugs in patients with osteoarthritis. J Rheumatol. 2000;27:1020-1027.Google Scholar
  47. 47.
    Herrero-Beaumont G, Ivorra JA, Del Carmen Trabado M, et al. Glucosamine sulfate in the treatment of knee osteoarthritis symptoms: a randomized, double-blind, placebo-controlled study using acetaminophen as a side comparator. Arthritis Rheum. 2007;56:555-567.Google Scholar
  48. 48.
    Massó González EL, Patrignani P, Tacconelli S, García Rodríguez LA. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010;62:1592-1601.Google Scholar
  49. 49.
    McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA. 2006;296:1633-1644.Google Scholar
  50. 50.
    Rao PNP, Knaus EE. Evolution of nonsteroidal anti-inflammatory drugs (NSAIDs): cyclooxygenase (COX) inhibition and beyond. J Pharm Pharm Sci. 2008;11:81 s-110 s.Google Scholar
  51. 51.
    Patrignani P, Tacconelli S, Bruno A, Sostres C, Lanas A. Managing the adverse effects of nonsteroidal anti-inflammatory drugs. Expert Rev Clin Pharmacol. 2011;4:605-621.Google Scholar
  52. 52.
    Lanas A, Garcia-Rodriguez LA, Polo-Tomás M, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol. 2009;104:1633-1641.Google Scholar
  53. 53.
    Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ. 2011;342:c7086.Google Scholar
  54. 54.
    Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2005;CD005328.Google Scholar
  55. 55.
    Rutjes AW, Jüni P, da Costa BR, Trelle S, Nüesch E, Reichenbach S. Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med. 2012;157:180-191.Google Scholar
  56. 56.
    Chappell AS, Desaiah D, Liu-Seifert H, et al. A double-blind, randomized, placebo-controlled study of the efficacy and safety of duloxetine for the treatment of chronic pain due to osteoarthritis of the knee. Pain Pract. 2011;11:33-41.Google Scholar
  57. 57.
    Bijlsma JWJ, Berenbaum F, Lafeber FPJG. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011;377:2115-2126.Google Scholar
  58. 58.
    Hochberg MC. Structure-modifying effects of chondroitin sulfate in knee osteoarthritis: an updated meta-analysis of randomized placebo-controlled trials of 2-year duration. Osteoarthritis Cartilage. 2010;18:S28-S31.Google Scholar
  59. 59.
    Matthews GL, Hunter DJ. Emerging drugs for osteoarthritis. Expert Opin Emerg Drugs. 2011;16:479-491.Google Scholar
  60. 60.
    Hunter DJ. Pharmacologic therapy for osteoarthritis – the era of disease modification. Nat Rev Rheumatol. 2011;7:13-22.Google Scholar
  61. 61.
    Richmond JC. Surgery for osteoarthritis of the knee. Rheum Dis Clin North Am. 2008;34:815-825.Google Scholar
  62. 62.
    Hall MJ, Lawrence L. Ambulatory surgery in the United States, 1996. Adv Data. 1998;300:1-16.Google Scholar
  63. 63.
    Brinker MR, O’Connor DP, Pierce P, Woods GW, Elliott MN. Utilization of orthopaedic services in a capitated population. J Bone Joint Surg Am. 2002;84-A:1926-1932.Google Scholar
  64. 64.
    Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81-88.Google Scholar
  65. 65.
    Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359:1097-1107.Google Scholar
  66. 66.
    Brouwer RW, Bierma-Zeinstra SMA, Verhagen AP, Jakma TSC, Verhaar JAN. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. 2007;(3):CD004019.Google Scholar
  67. 67.
    Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The Install Award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year follow-up study. Clin Orthop Relat Res. 1999;367:18-27.Google Scholar
  68. 68.
    Stukenborg-Colsman C, Wirth CJ, Lazovic D, Wefer A. High tibial osteotomy versus unicompartmental joint replacement in unicompartmental knee joint osteoarthritis: 7–10-year follow-up prospective randomised study. Knee. 2001;8:187-194.Google Scholar
  69. 69.
    Mancuso CA, Ranawat CS, Esdaile JM, Johanson NA, Charlson ME. Indications for total hip and total knee arthroplasties. Results of orthopaedic surveys. J Arthroplasty. 1996;11:34-46.Google Scholar
  70. 70.
    Fortin PR, Clarke AE, Joseph L, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999;42:1722-1728.Google Scholar

Copyright information

© Springer Healthcare 2014

Authors and Affiliations

  • David Hunter
    • 1
  1. 1.University of Sydney; Royal North Shore Hospital, North Sydney Orthopaedic and Sports Medicine CentreSydneyAustralia

Personalised recommendations